Kate L. Lapane

Appropriate prescribing in elderly people: how well can it be measured and optimised?

Prescription of medicines is a fundamental component of the care of elderly people, and optimisation of drug prescribing for this group of patients has become an important public-health issue worldwide. Several characteristics of ageing and geriatric medicine affect medication prescribing for elderly people and render the selection of appropriate pharmacotherapy a challenging and complex process. In the first paper in this series we aim to define and categorise appropriate prescribing in elderly people, critically review the instruments that are available to measure it and discuss their predictive validity, critically review recent randomised controlled intervention studies that assessed the effect of optimisation strategies on the appropriateness of prescribing in elderly people, and suggest directions for future research and practice.

Sulfonylureas and risk of falls and fractures among nursing home residents with type 2 diabetes mellitus

AIMS Although sulfonylureas increase the risk of hypoglycemia which may lead to fall-associated fractures, studies quantifying the association between sulfonylureas and falls and/or fractures are sparse and existing studies have yielded inconsistent results. Our objective is to evaluate the extent to which sulfonylurea use was associated with fractures and falls among nursing home residents with type 2 diabetes mellitus. METHODS We performed a propensity-matched retrospective new user cohort study of 12,327 Medicare Parts A/B/D eligible long-stay NH residents. Medicare Part D data provided information on sulfonylurea and biguanide use initiated as monotherapy (nsulfonylurea=5807 and nbiguanide=6151) after NH entry. Medicare hospitalizations were used to identify hypoglycemic events (ICD-9-CM codes 250.8, 251.1, 251.2) and fall-associated fractures (ICD-9-CM codes 800, 804, 812-817, 820, 823, 824). Minimum Data Set 2.0 (2008-2010) provided information on falls and potential confounders. Cox models conducted on propensity-matched samples provided adjusted hazard ratio (aHR) estimates and 95% confidence intervals (CI). RESULTS Falls were common (37.4 per 100 person-years). Fractures were not associated with initiation of sulfonylureas. Sulfonylurea initiation was associated with an excess risk of falls among residents with moderate activities of daily living limitations (aHR: 1.13; 95% CI: 1.00-1.26), but not among those with minimal limitations or dependence in activities of daily living. CONCLUSIONS Nursing home residents with moderate limitations in activities of daily living are at increased risk of falls upon initiation of sulfonylureas. Initiating sulfonylurea use in NH residents must be done with caution.

Correlates and Management of Nonmalignant Pain in the Nursing Home

Nonmalignant pain is a common problem among older people. The prevalence of pain in the nursing home is not well studied. We looked at the association between nonmalignant pain, psychological and functional health, and the practice patterns for pain management in the nursing home.

Overweight in Children and Adolescents in Relation to Attention-Deficit/Hyperactivity Disorder: Results From a National Sample

OBJECTIVE. As the prevalence of childhood obesity increases, identifying groups of children who are at increased risk of overweight is important. The current study estimated the prevalence of overweight in children and adolescents in relation to attention-deficit/hyperactivity disorder and medication use. PATIENTS AND METHODS. This study was a cross-sectional analysis of 62 887 children and adolescents aged 5 to 17 years from the 2003–2004 National Survey of Childrens Health, a nationally representative sample of children and adolescents in the United States. Attention-deficit disorder/attention-deficit/hyperactivity disorder was determined by response to the question “Has a doctor or health professional ever told you that your child has attention-deficit disorder or attention-deficit/hyperactive disorder, that is, ADD or ADHD?” Children and adolescents were classified as underweight, normal weight, at risk of overweight, or overweight according to BMI for age and gender. RESULTS. After adjustment for age, gender, race/ethnicity, socioeconomic status, and depression/anxiety, children and adolescents with attention-deficit disorder/attention-deficit/hyperactivity disorder not currently using medication had ∼1.5 times the odds of being overweight, and children and adolescents currently medicated for attention-deficit disorder/attention-deficit/hyperactivity disorder had ∼1.6 times the odds of being underweight compared with children and adolescents without either diagnosis. CONCLUSIONS. This study provides heightened awareness for pediatric providers about the relationship between attention-deficit disorder/attention-deficit/hyperactivity disorder, medication use, and weight status. Future work is needed to better understand the longitudinal and pharmacologic factors that influence the relationship between attention-deficit disorder/attention-deficit/hyperactivity disorder and weight status in children and adolescents.

Does Receipt of Hospice Care in Nursing Homes Improve the Management of Pain at the End of Life

To compare analgesic management of daily pain for dying nursing home residents enrolled and not enrolled in Medicare hospice.

Persistent Nonmalignant Pain and Analgesic Prescribing Patterns in Elderly Nursing Home Residents

Objectives: To determine the prevalence of analgesics used, their prescribing patterns, and associations with particular diagnoses and medications in patients with persistent pain.

Hyperhomocysteinemia and traditional cardiovascular disease risk factors in end-stage renal disease patients on dialysis: a case-control study

Hyperhomocysteinemia occurs frequently in end-stage renal disease (ESRD), but its prevalence in comparison with traditional cardiovascular disease (CVD) risk factors is unknown. Fasting total plasma homocysteine, potential determinants of plasma homocysteine (i.e., plasma B-vitamins and serine), total and HDL cholesterol, glucose, and creatinine, were determined in 24 ESRD patients on dialysis, and 24 age, gender, and race matched Framingham Offspring Study controls with normal renal function. Presence of clinical CVD and CVD risk factors was established by standardized methods. Mean plasma homocysteine was markedly higher in the ESRD patients versus controls (22.7 vs. 9.5 mumol/l). ESRD patients were 33 times more likely than controls to have hyperhomocysteinemia (> 15.8 mumol/l) (95% confidence interval, 5.7-189.6). Hyperhomocysteinemia persisted in the ESRD patients despite normal to supernormal B-vitamin status. Plasma serine levels below the tenth percentile of the control distribution were found in 75% of the ESRD patients. Oral serine supplementation caused a 37% increase in mean plasma serine, but had no effect on plasma homocysteine in four ESRD patients with supernormal plasma folate, low plasma serine, and hyperhomocysteinemia. Given its unusually high prevalence, improved management of hyperhomocysteinemia might reduce CVD sequelae in ESRD.

Management of heart failure among very old persons living in long-term care: Has the voice of trials spread?☆☆☆★★★

Abstract Background Increasing prevalence, use of health services, and number of deaths have made congestive heart failure (CHF) a new epidemic in the United States. Yet there are no adequate data to guide treatment of the more typical and complex cases of patients who are very old and frail. Methods Using the SAGE database, we studied the cases of 86,094 patients with CHF admitted to any of the 1492 long-term care facilities of 5 states from 1992 through 1996. We described their clinical and functional characteristics and their pharmacologic treatment to verify agreement with widely approved guidelines. We evaluated age- and sex-related differences, and we determined predictors of receiving an angiotensin-converting enzyme (ACE) inhibitor by developing a multiple logistic regression model. Results The mean age of the population was 84.9 ± 8 years. Eighty percent of the patients 85 years of age or older were women. More than two thirds of patients underwent frequent hospitalizations related to CHF in the year preceding admission to a long-term care facility. Coronary heart disease and hypertension were the most common causes. Half of the patients received digoxin and 45% a diuretic, regardless of background cardiovascular comorbidities. Only 25% of patients had a prescription for ACE inhibitors. The presence of cardiovascular comorbidity, already being a recipient of a large number of medications, a previous hospitalization for CHF, and admission to the facility in recent years were associated with an increased likelihood of receiving an ACE inhibitor. The presence of severe physical limitation was inversely related to use of ACE inhibitors, as were a series of organizational factors related to the facilities. Conclusions Patients in long-term care who have CHF little resemble to those enrolled in randomized trials. This circumstance may explain, at least in part, the divergence from pharmacologic management consensus guidelines. Yet the prescription of ACE inhibitors varies significantly across facilities and depends on organizational characteristics. (Am Heart J 2000;139:85-93.)

Possible Influence of the Prospective Payment System on the Assignment of Discharge Diagnoses for Coronary Heart Disease

BACKGROUND The prospective payment system, under which diagnosis-related groups (DRGs) are used to reimburse hospitals for the care of Medicare patients, replaced the fee-for-service method of payment in Rhode Island in 1983 and in Massachusetts in 1985. Changes in financial incentives resulting from the use of the DRG system may have influenced the assignment of discharge diagnostic codes away from those with lower reimbursement toward codes with higher reimbursement. METHODS We collected data from the hospital records of patients 35 through 74 years of age who were discharged with codes 410 through 414 (representing various categories of coronary heart disease) of the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). The patients were discharged from seven hospitals in two New England communities (one in Rhode Island and one in Massachusetts) between 1980 and 1988. The rates of diagnosis of various forms of coronary heart disease were determined by studying ICD-9-CM hospital discharge codes (codes 410 and 411 for acute forms of coronary heart disease and codes 412, 413, and 414 for chronic forms) and by using a computerized diagnostic algorithm designed to detect definite myocardial infarction and fatal coronary heart disease. RESULTS The rates of definite coronary events diagnosed by the algorithm and by the study of ICD-9-CM codes 410 through 414 were constant or increased slightly during the study period. However, the frequency of assignment of codes for the acute forms of coronary heart disease (which entail higher reimbursement) rose from 35.2 percent to 48.4 percent among discharged patients with cardiac disease after the institution of DRGs. The majority of this increase was associated with the code for unstable angina pectoris. The frequency of assignment of codes for the chronic forms of coronary heart disease (which entail lower reimbursement) decreased reciprocally, from 64.8 percent to 51.6 percent (P < 0.001). CONCLUSIONS Our data are consistent with the hypothesis that the prospective reimbursement system has influenced the assignment of hospital discharge codes in a way that would increase payment to hospitals. However, the data do not permit us to distinguish whether hospitals began to assign more precise diagnoses with the advent of the DRG system, or whether they began to favor diagnoses of acute conditions solely for financial reasons.

Influence of facility characteristics on use of antipsychotic medications in nursing homes.

Objectives.This study investigated the effect of facility and resident characteristics on the use of antipsychotic medications in the long-term care setting. Research Design.This research used data available from the On-Line Survey and Certification of Automated Records (OSCAR) for all Medicare/Medicaid-certified nursing homes in the contiguous United States in 1997. The data consisted of 14,631 facilities. Measures.A multiple linear regression model was used to determine the effects of selected facility and resident characteristics on antipsychotic drug use while simultaneously controlling for the effects of resident characteristics and stratifying by ownership type. &bgr;-Coefficients provided measures of effect and represented the per-unit change in the prevalence of antipsychotic use corresponding to the per-unit change in each independent variable. Results.In for-profit facilities, both the presence of special care units and mental health professionals were associated with increased antipsychotic use (&bgr; = 1.70, SE = 0.23; &bgr; = 0.24, SE = 0.17, respectively), while other facility factors such as increasing size, being part of a chain, and higher occupancy rate were associated with decreased antipsychotic drug use. In the nonprofit environment, facility characteristics (eg, increasing occupancy rate, certified nurses’ aides per 100 beds) were associated with decreasing antipsychotic use. Increasing percentages of residents covered by Medicare, those with dementia, and residents with mental retardation (&bgr; = 0.05, SE = 0.01; &bgr; = 0.03, SE = 0.01; &bgr; = 0.08, SE = 0.08, respectively) were predictive of increased drug use. Conclusions.Facility and resident characteristics are associated with use of antipsychotic medications, although the extent to which these factors explain variability in use of antipsychotics may vary on the basis of the underlying financial incentives of the institution.